Failure to Follow Transfer Care Plan Results in Resident Fractures
Penalty
Summary
The facility failed to ensure a safe transfer for a resident who required staff assistance and use of a sit‑to‑stand lift for functional transfers. The resident had multiple medical conditions including rheumatoid arthritis, osteoarthritis, muscle weakness, repeated falls, unsteadiness of feet, low back pain, radiculopathy, and dementia, and had a BIMS score of 9 indicating moderate cognitive impairment. The resident’s MDS documented dependence on staff for transfers and moving from sitting to standing, and the care plan directed staff to complete functional transfers using a sit‑to‑stand lift due to impaired balance. A fall risk evaluation identified the resident as high risk for falls, and the Kardex and care plan identified the resident as a “lift stand transfer.” Despite these documented needs and interventions, a CNA transferred the resident to bed using a stand‑pivot technique from the wheelchair to the bed instead of using the ordered sit‑to‑stand lift. The resident later reported that during this transfer the staff member lifted them under the arms and around the chest to place them in bed, and that a loud noise occurred at that time, which the resident described as sounding like a gunshot. The CNA reported hearing a noise during the transfer and believed it was the Velcro strap on the resident’s shoes, and the resident did not complain of pain at that time. No documentation in the report indicates that the CNA verified the resident’s transfer status or used the required mechanical lift during this transfer. The next morning, the resident complained of severe left leg and foot pain to an LPN, stating they thought their leg was broken and attributing the injury to the transfer the previous night when their foot hit the side of the bed. Subsequent nursing assessment identified swelling and tenderness of the left ankle and foot. An x‑ray of the left ankle revealed oblique fractures of the distal tibia and fibula with modest displacement and minimal callus formation. The resident was later admitted to the hospital with a diagnosis of closed fracture of the left tibia and fibula and underwent intramedullary rod insertion of the left tibia. The deficiency centers on the failure to follow the resident’s care plan and transfer requirements by not using the sit‑to‑stand lift during the transfer, which was associated with the resident sustaining fractures to the left ankle region.
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